Recent advances in delivering implant treatment are nothing short of the spectacular. In times that breed “immediate gratification” of the consumer at large, the development of Teeth-in-an-Hour protocol (Nobel Biocare-Procera)1 fits in well with the historical evolution of dental implants. Thanks to the graciousness of the team at University of Michigan, I had a chance to review, first hand, this new development. After an intensive day of scrutiny my thoughts quickly turned to a quote I recently read in Margaret MacMillan’s2 outstanding book about the treaty of Versailles. “I have seen the future and it works,” said Lincoln Steffens, one of the most prominent journalists of the day, after witnessing the Russian Revolution in 1917. Considering the fate of Communism, Steffens comments should be rewritten (“I have seen the future but it did not work”), because the new social order did failed, albeit 70 years later (fall of the Berlin wall November 9th, 1989). Later on that day in Michigan, when the powder from the latex gloves settled, I had second and more provoking thoughts.
The system works like this3 (in parenthesis note the very approximate fees in US$): a maxillary fully edentulous patient with some or intact mandibular dentition, is sent for two CT scans; one scan with the denture in place (new and modified upper denture is needed in most cases, U$800 – my estimation) and another scan of the denture attached to a Styrofoam block (no cost for the block). With the help of a proprietary piece of software (US$4,000), by using the two scans (US$1,600), the trained practitioner then completes the treatment plan, bloodless so to speak, on the monitor. The surgical plan that includes the precise position of the implants is then sent to Sweden where, a special laboratory will fabricate the final prosthesis (cost for all these is about US$ 4,000). In about a week’s time, the lab will send a surgical template and the final prosthesis back to the practitioner. So far, this is nothing earth shattering, except for the innovative and well designed and “oiled” software.
Most of the mental torments that I had experienced since the “wow” moments of the presentation resulted from the following issues. The first lies in the “surgery” itself. According to the protocol the patient comes to the office and the “surgery” commences. After rigid fixation of the surgical template to the edentulous maxilla by means of three titanium pins (please note that for accurate positioning of the template before fixation to the maxilla requires at least a handful of teeth in the mandible) the surgeon installs the implants without elevating a flap. The “surgery” is perplexing in its simplicity. It is a “blind and flapless” procedure that lasts about 40 minutes; the slightly modified drills are accurately guided by the template for the preparation of the implant sites. Once all the implants are in place (at least six) the final denture is installed immediately (fully fixed detachable type) and the patient can go to the cafeteria to try out the new “In-an-Hour” Teeth.
The experienced staff surgeon from University of Michigan, who was accredited to have done the first of this kind in the US, had confessed that it was an embarrassingly simple surgery.
It appears that there are several real technical issues to be worked out (I have a long list of it) before this method is ready for large-scale consumption. Although the method is short on patient-case experience and documentation and long on anecdotal evidence this “future may work”. It is innovative and very attractive to the consumer.
Second, I have conceptual questions with more profound implications than technical fine-tuning there is still required. Do we need well-trained surgeons for this procedure or anybody could do it? Could we train second year dental students in it before they learn how to scale or cut a prep? Being touted as a simple procedure, would other health care providers (ENT, plastic surgeons or dermatologists for example) complement their income on a slow (Botox) day by doing a few implant cases as well?
Whereas having “Teeth-in-an Hour” undoubtedly presents great consumer appeal, is it cost effective? How much can I charge for a “bloodless surgery” that lasts 40 minutes, but requires a lot of preparation? Is it reasonable to expect, at significant cost, to have “Teeth-in-an-Hour” for somebody who has been edentulous for many years or decades? Can we take the leap of faith to flapless surgery with abandon? Can we trust the accuracy of the latest science and technology at a tolerance level of plus/minus 0.5mm?
The reader should note that other companies, such as 3i Implant Innovations–Palm Beach Gardens, Florida, USA) are/have developed products utilizing computer aided design and manufacturing.
I could not answer these questions well in spite of the fact that I am an intense practitioner and educator and one who has seen the evolution of implant dentistry first hand form its infancy to its current practice.
I would hate to suffer the fate of the poor Lincoln Steffens, and be proven wrong in time. His readers should have been suspicious of his statement from the beginning because, by definition you cannot “see” the future today. Hence, I will stick with my own version “I have seen the future and it might work”. What do you think?
1.FDA clearance for Nobel Biocare’s Teeth-in-an-Hour implant system; February 2004
2.Paris1919. Six Months that Changed the World. Margaret MacMillan. (Random House)